A Novel and Accurate Palpation Method for Identification of the L4 Spinous Process: A Preliminary Study of Accuracy.

OBJECTIVE: The purpose of this study was to assess a novel method of lumbar spinous process (SP) palpation by using magnetic resonance imaging (MRI) high-signal marker reference standards for verification. METHODS: Clinicians (doctors of chiropractic) in this study used either: (1) the standard/traditional method of identifying the L4 SP using the supracristal plane (n = 14) or (2) a novel method that manually induced sacral motion to identify the L5 and then the L4 SP (n = 54). The clinicians, blinded to the results of each other, used a grease pencil to mark the location identified as the L4 SP. An MRI high-signal marker then was taped across this location. The MRI scans were assessed by a radiologist, blinded to the palpation method, who extended a line posteriorly from the superior and inferior extent of the L4 SP and determined whether the high-signal marker was within the lines bordering the L4 SP (ie, "on-target"). RESULTS: Palpation using the traditional method showed a 35.7% accuracy, with 5 of 14 "on target" and all "off target" being too superior. Palpation using the novel method showed 77.8% accuracy, with 42 of 54 "on target" and 3 "off target" being too superior and 9 "off target" too inferior. CONCLUSIONS: The novel method performed better than the traditional method. The novel method shows promise. Additional prospective research should be conducted to fully assess the accuracy of the novel method compared with traditional methods of palpation.

Magnetic resonance imaging zygapophyseal joint space changes (gapping) in low back pain patients following spinal manipulation and side-posture positioning: a randomized controlled mechanisms trial with blinding.

OBJECTIVE: The purpose of this study was to quantify lumbar zygapophyseal (Z) joint space separation (gapping) in low back pain (LBP) subjects after spinal manipulative therapy (SMT) or side-posture positioning (SPP). METHODS: This was a controlled mechanisms trial with randomization and blinding. Acute LBP subjects (N = 112; four n = 28 magnetic resonance imaging [MRI] protocol groups) had 2 MRI appointments (initial enrollment and after 2 weeks of chiropractic treatment, receiving 2 MRI scans of the L4/L5 and L5/S1 Z joints at each MRI appointment. After the first MRI scan of each appointment, subjects were randomized (initial enrollment appointment) or assigned (after 2 weeks of chiropractic treatment appointment) into SPP (nonmanipulation), SMT (manipulation), or control MRI protocol groups. After SPP or SMT, a second MRI was taken. The central anterior-posterior joint space was measured. Difference between most painful side anterior-posterior measurements taken postintervention and preintervention was the Z joint "gapping difference." Gapping differences were compared (analysis of variance) among protocol groups. Secondary measures of pain (visual analog scale, verbal numeric pain rating scale) and function (Bournemouth questionnaire) were assessed. RESULTS: Gapping differences were significant at the first (adjusted, P = .009; SPP, 0.66 ± 0.48 mm; SMT, 0.23 ± 0.86; control, 0.18 ± 0.71) and second (adjusted, P = .0005; SPP, 0.65 ± 0.92 mm; SMT, 0.89 ± 0.71; control, 0.35 ± 0.32) MRI appointments. Verbal numeric pain rating scale differences were significant at first MRI appointment (P = .04) with SMT showing the greatest improvement. Visual analog scale and Bournemouth questionnaire improved after 2 weeks of care in all groups (both P < .0001). CONCLUSIONS: Side-posture positioning showed greatest gapping at baseline. After 2 weeks, SMT resulted in greatest gapping. Side-posture positioning appeared to have additive therapeutic benefit to SMT.

Quantification of cavitation and gapping of lumbar zygapophyseal joints during spinal manipulative therapy.

OBJECTIVES: The purpose of this study was to use previously validated methods to quantify and relate 2 phenomena associated with chiropractic spinal manipulative therapy (SMT): (1) cavitation and (2) the simultaneous gapping (separation) of the lumbar zygapophyseal (Z) joint spaces. METHODS: This was a randomized, controlled, mechanistic clinical trial with blinding. Forty healthy participants (18-30 years old) without a history of low-back pain participated. Seven accelerometers were affixed to the skin overlying the spinous processes of L1 to L5 and the S1 and S2 sacral tubercles. Two additional accelerometers were positioned 3 cm left and right lateral to the L4/L5 interspinous space. Participants were randomized into group 1, side-posture SMT (n = 30), or group 2, side-posture positioning (SPP, n = 10). Cavitations were determined by accelerometer recordings during SMT and SPP (left side = upside for both groups); gapping (gapping difference) was determined by the difference between pre- and postintervention magnetic resonance imaging scan joint space measurements. Results of mean gapping differences were compared. RESULTS: Upside SMT and SPP joints gapped more than downside joints (0.69 vs -0.17 mm, P < .0001). Spinal manipulative therapy upside joints gapped more than SPP upside joints (0.75 vs 0.52 mm, P = .03). Spinal manipulative therapy upside joints gapped more in men than in women (1.01 vs 0.49 mm, P < .002). Overall, joints that cavitated gapped more than those that did not (0.56 vs 0.22 mm, P = .01). No relationship was found between the occurrence of cavitation and gapping with upside joints alone (P = .43). CONCLUSIONS: Zygapophyseal joints receiving chiropractic SMT gapped more than those receiving SPP alone; Z joints of men gapped more than those of women, and cavitation indicated that a joint had gapped but not how much a joint had gapped.

Evaluating the relationship among cavitation, zygapophyseal joint gapping, and spinal manipulation: an exploratory case series.

OBJECTIVE: This project determined the feasibility of conducting larger studies assessing the relationship between cavitation and zygapophyseal (Z) joint gapping following spinal manipulative therapy (SMT). METHODS: Five healthy volunteers (average age, 25.4 years) were screened and examined against inclusion and exclusion criteria. High-signal magnetic resonance imaging (MRI) markers were fixed to T12, L3, and S1 spinous processes. Scout images were taken to verify the location of the markers. Axial images of the L4/L5 and L5/S1 levels were obtained in the neutral supine position. Following the first MRI, accelerometers were placed over the same spinous processes; and recordings were made from them during side-posture positioning and SMT. The accelerometers were removed, and each subject was scanned in side-posture. The greatest central anterior to posterior Z joint spaces (gap) were measured from the first and second MRI scans. Values obtained from the first scan were subtracted from those of the second, with a positive result indicating an increase in gapping following SMT (positive gapping difference). Gapping difference was compared between the up-side (SMT) joints vs the down-side (non-SMT) joints and between up-side cavitation vs up-side noncavitation joints. RESULTS: Greater gapping was found in Z joints that received SMT (0.5 ± 0.6 mm) vs non-SMT joints (-0.2 ± 0.6 mm), and vertebral segments that cavitated gapped more than those that did not cavitate (0.8 ± 0.7 vs 0.4 ± 0.5 mm). CONCLUSIONS: A future clinical study is quite feasible. Forty subjects (30 in an SMT group and 10 in a control group) would be needed for appropriate power (0.90).

Reliability of zygapophysial joint space measurements made from magnetic resonance imaging scans of acute low back pain subjects: comparison of 2 statistical methods.

OBJECTIVE: This purpose of this study was to assess the reliability of measurements made of the zygapophysial (Z) joint space from the magnetic resonance imaging scans of subjects with acute low back pain using new equipment and 2 different methods of statistical analysis. If found to be reliable, the methods of Z joint measurement can be applied to scans taken before and after spinal manipulation in a larger study of acute low back pain subjects. METHODS: Three observers measured the central anterior-to-posterior distance of the left and right L4/L5 and L5/S1 Z joint space from 5 subject scans (20 digitizer measurements, rounded to 0.1 mm) on 2 separate occasions separated by 4 weeks. Observers were blinded to each other and their previous work. Intra- and interobserver reliability was calculated by means of intraclass correlation coefficients and also by mean differences using the methods of Bland and Altman (1986). A mean difference of less than +/-0.4 mm was considered clinically acceptable. RESULTS: Intraclass correlation coefficients showed intraobserver reliabilities of 0.95 (95% confidence interval, 0.87-0.98), 0.83 (0.62-0.92), and 0.92 (0.83-0.96) for each of the 3 observers and interobserver reliabilities of 0.90 (0.82-0.95), 0.79 (0.61-0.90), and 0.84 (0.75-0.90) for the first and second measurements and overall reliability, respectively. The mean difference between the first and second measurements was -0.04 mm (+/-1.96 SD = -0.37 to 0.29), 0.23 (-0.48 to 0.94), 0.25 (-0.24 to 0.75), and 0.15 (-0.44 to 0.74) for each of the 3 observers and the overall agreement, respectively. CONCLUSIONS: Both statistical methods were found to be useful and complementary and showed the measurements to be highly reliable.

Dimensions of the lumbar intervertebral foramina as determined from the sagittal plane magnetic resonance imaging scans of 95 normal subjects.

OBJECTIVES: This was a 2-part study. Part 1 evaluated the reliability of measurements of the intervertebral foramina (IVF) from magnetic resonance imaging (MRI) scans, and part 2 developed a morphometric database of IVF dimensions from normal living subjects. DESIGN: Part 1 was a blinded reliability study using 7 observers, and part 2 developed a morphometric database using 2 teams of 3 observers, all blinded to the results of each other. SUBJECTS: Ninety-five normal subjects (46 women, 49 men) were stratified by age (range 14-84 years, average 38.8 years). OUTCOME MEASURES: Part 1: Interclass correlation coefficients (ICCs) were calculated for intraobserver and interobserver reliability for 3 dimensions of the lumbar IVFs. Part 2: A database was developed using the same measures. In addition, the relationships between IVF dimensions and age, height, weight, sex, and left versus right sides of subjects were evaluated. RESULTS: Part 1: All ICCs were very high (> 0.94). Part 2: 8550 measurements were made, and a morphometric database of 95 subjects, stratified by age and sex, was completed. Differences in IVF size associated with age, height, weight, sex, and side were described. CONCLUSIONS: Measurements taken from MRI scans of IVFs were performed reliably. The morphometric database and IVF relationships should aid clinicians and researchers in evaluating patients with suspected foraminal stenosis and help further investigate IVF pathology and treatment of such pathology.

The effects of side-posture positioning and spinal adjusting on the lumbar Z joints: a randomized controlled trial with sixty-four subjects.

STUDY DESIGN: A blinded, randomized controlled trial was conducted. OBJECTIVE: To test the hypothesis that chiropractic side-posture manipulation (adjusting) of the lumbar spine separates (gaps) the zygapophysial (Z) joints. SUMMARY OF BACKGROUND DATA: Spinal adjusting is thought to gap the Z joints, yet no studies have conclusively validated this hypothesis, and some investigators have reported that the lumbar Z joints do not gap during rotation. METHODS: For this study, 64 healthy student volunteers (32 men and 32 women) ages 22 to 30 years with no history of significant low back pain were randomized into four groups of 8 men and 8 women each. Interventions included lumbar side-posture spinal adjusting (manipulation) and side-posture positioning. Anterior to posterior measurements of the Z joints from MRI scans taken before and after side-posture spinal adjusting and before and after side-posture positioning were compared. RESULTS: Observers performing the measurements were blinded as to group and first and second scans. Reliability of the measurements was established. Differences were found between the groups (F = 24.15; P < 0.000, analysis of variance). Side-posture positioning showed greater gapping than the control condition (mean difference, 1.18; P < 0.000); side-posture adjusting showed greater gapping than the control condition (mean difference, 1.89; P < 0.000), and side-posture adjusting showed greater gapping than side-posture positioning (mean difference, 0.71; P = 0.047). CONCLUSIONS: Spinal adjusting produced increased separation (gapping) of the Z joints. Side-posture positioning also produced gapping, but less than that seen with lumbar side-posture adjusting. This study helps to increase understanding about the mechanism of action for spinal manipulation.